Challenges and Controversies in Foot and Ankle Trauma.

Management of foot and ankle trauma continues to evolve and change. It is important to be informed about the latest challenges and controversies in management of these injuries, which include ankle fractures, calcaneus fractures, Lisfranc injuries, and Jones fracture. Important concepts related to ankle fracture are the changing indications for surgery, utilization of stress radiographs, the role of arthroscopy, repair of the deltoid ligament, fixation of the posterior malleolus, and diagnosis and treatment of syndesmotic injuries. Regarding calcaneus fractures, discussion revolves around defining indications for fixation, factors that influence outcomes, less invasive approaches versus traditional extensile exposures, and the nature of the constant fragment. With Lisfranc injuries, the orthopaedic surgeon should be aware of fixation methods as well as the issue of fixation versus fusion. Discussion of Jones fracture should include evaluation of indications and different fixation techniques.

Arthroscopic Tibiotalar Arthrodesis Using an Arthroscopic Autologous Tissue Collector: A Technique Guide.

Tibiotalar arthrodesis is a common procedure performed in patients with ankle arthritis to relieve pain, restore function, and improve the quality of life. Obtaining proper bone-to-bone apposition is crucial to obtaining a solid fusion. Therefore, adequate joint preparation is critical. Open-joint preparation is the standard of care, but arthroscopic arthrodesis is becoming increasingly popular, as it can decrease tissue trauma, postoperative pain, hospital stay, and complications. The addition of bone matrix allograft and autograft also improves healing rates. Use of an arthroscopic autologous tissue collector through standard arthroscopic portals allows harvesting of bone matrix autograft without having to perform additional invasive bone harvesting outside of the affected joint. We present our technique for tibiotalar arthrodesis using an arthroscopic approach with an arthroscopic autologous tissue collector.

Utilization of minimally invasive burr for surgical correction of calcaneus fracture malunion: A case report describing a novel technique.

INTRODUCTION: Calcaneus fractures pose a significant treatment challenge to orthopaedic surgeons. Nonoperative treatment frequently leads to malunion, persistent pain, and development of subtalar arthritis, while operative treatment increases the risk of surgical-related complications, such as surgical site infection, without demonstrating superior outcomes. PRESENTATION OF CASE: A 58-year-old male laborer presented three months after sustaining a left joint-depression type calcaneus fracture. He was initially treated nonoperatively but suffered from significant pain and dysfunction interfering with activities of daily living and inability to return to work. The patient was treated with a novel technique utilizing a minimally invasive burr to correct calcaneus fracture malunion. There were no reported post-operative complications, including infection or additional malunion, patient has returned to normal shoewear and his physically demanding career. DISCUSSION: This is one of few studies documenting utilization of a minimally invasive burr for surgical correction of calcaneus fracture malunion. Restoration of calcaneal height and hindfoot alignment were achieved without evidence of subtalar arthritis on postoperative radiographs. Minimally invasive surgical procedures, especially with smaller incisions, have been found to be just as effective as open, though with significantly fewer wound and nerve complications. CONCLUSION: Minimally invasive correction of calcaneus fracture malunion may be a viable option for surgical intervention, even in patients who are at higher risk of surgical complications such as infection. The indications for minimally invasive techniques are rapidly expanding and further studies are warranted to evaluate the use of minimally invasive techniques in foot and ankle surgery.

Chronic insertional Achilles tendinopathy secondary to congenital os Achilles: A case report.

INTRODUCTION: Insertional Achilles tendinopathy is a common overuse disorder affecting the foot and ankle that can lead to the development of a Haglund's deformity with chronicity, a retrocalcaneal exostosis that forms at the Achilles insertion site, further increasing pain and dysfunction. PRESENTATION OF CASE: We report a case of a healthy, 35-40-year-old male with chronic left-sided insertional Achilles pain beginning in early adolescence. Physical exam demonstrated bilateral prominences on the posterior aspect of both heels, exquisitely tender on the left and without range of motion deficits. Imaging demonstrated a large calcific ossicle clearly within the tendinous insertion of the Achilles onto the left calcaneus. He underwent surgical intervention to provide pain relief and restore function. He exhibited full recovery post-operatively and has now returned to full functional activities. DISCUSSION: Given his symptom pathogenesis and progression, this patient may likely have suffered from chronic insertional Achilles tendinopathy due to an accessory ossicle that we believe was congenital. Current literature describes an additional secondary ossification center that appears over the dorsal, posterosuperior surface of the calcaneus. We suspect that there was a lapse in fusion at this additional ossification center that contributed to his pathological condition. CONCLUSION: This case report presents a unique occurrence of Achilles tendinopathy likely due to an accessory ossicle of congenital etiology. This highlights the importance of investigating the prevalence of this condition in those with chronic insertional Achilles tendinopathy, thus providing meaningful insight in considering effective treatment modalities in the management of these patients.

Student loan debt and financial education: a qualitative analysis of resident perceptions and implications for resident well-being.

High educational debt is prevalent among resident physicians and correlates with adverse well-being outcomes, including symptoms of stress and burnout. Residents also report low financial literacy levels, affecting financial well-being. Understanding resident viewpoints toward financial well-being initiatives is crucial to develop targeted resident financial well-being programs. This study aims to examine residents' experiences financing their medical education and how these experiences influence well-being and attitudes toward financial education in residency. We recruited residents from a Southern California health system with residency programs in Family Medicine, Internal Medicine, General Surgery, Orthopaedic Surgery, and Psychiatry. We contacted residents by email and text message to participate in semi-structured interviews. We conducted interviews from October 2020 to March 2021 and analyzed 59 resident interviews using reflexive thematic analysis. Among residents, 76% (45/59) had ≥ $200,000 in student loans. Residents perceived mounting medical education debt as unfairly burdensome for trainees engaged in socially beneficial work, leaving residents feeling undervalued - a feeling heightened by the stressors of the COVID-19 pandemic - and hampering well-being. Compartmentalizing debt attenuated financial stressors but often made financial education seem less pressing. A subset of residents described how financial planning restored some agency and enhanced well-being, noting that protected didactic time for financial education was crucial. Resident interviews provide practical guidance regarding designing financial education sessions. Desired education included managing debt, retirement planning, and the business of medicine. How residents framed educational debt and their degree of financial literacy impacted their well-being and sense of agency. Residents proposed that residency programs can aid in stress mitigation by providing residents with skills to help manage debt and plan for retirement. To reduce clinician indebtedness, this approach needs to occur in tandem with systemic changes to financing medical education.

Management of twenty centimeter segmental bone defect of femoral shaft secondary to infected non-union of fracture using masquelet technique: A case report.

INTRODUCTION: Segmental bone loss is a challenging condition to manage, and some of the techniques employed are difficult for patients to tolerate and involve lengthy treatment and rehabilitation times. The Masquelet technique is a two-stage bone grafting technique used to treat segmental bone defects. The technique has primarily been described for bone defects averaging 5.5 cm in length. This technique's advantages include protection against autograft resorption, relative maintenance of graft position, and prevention of soft-tissue interposition. We present a case report of a male who achieved successful bone defect union utilizing the Masquelet technique for a right femoral shaft infected non-union with a resultant 20 cm bone defect. CASE REPORT: This is a case report of a 28-year old male who presented to our clinic for evaluation and treatment for a segmental bone defect secondary to a right femur fracture with non-union after infection. The patient had been in a motor vehicle collision. Our patient was interested in limb salvage surgery and declined bone transport. Given the significant size of his defect, we opted to treat him utilizing the Masquelet technique. He went on to have a successful union of his defect with associated increased subjective quality of life and functionality. CONCLUSION: The Masquelet technique is a useful limb salvage treatment for patients with segmental bone defects, including large defects of 20 cm in length.

Correlating Arthroscopic and Radiographic Findings of Deep Deltoid Ligament Injuries in Rotational Ankle Fractures.

BACKGROUND: The deep deltoid ligament (DDL) is a key stabilizer to the medial ankle and ankle mortise and can be disrupted in ligamentous supination external rotation type IV (LSER4) ankle fractures. The purpose of this study was to define the medial clear space (MCS) measurement on injury mortise radiographs that corresponds with complete DDL injury. METHODS: A retrospective record review at a level 1 hospital was performed identifying patients with LSER4 ankle fractures who underwent arthroscopy and open reduction internal fixation. Chart reviews provided arthroscopic images and operative reports. Complete DDL injury was defined as arthroscopic visualization of the posterior tibial tendon (PTT). Inability to completely visualize the PTT was defined as a partial DDL injury. MCS was measured on injury mortise radiographs. Eighteen subjects met inclusion criteria. RESULTS: Twelve subjects had complete and 6 subjects had partial DDL injury based on arthroscopic findings. Patients with complete DDL injury and those with partial DDL injury had injury radiograph MCS ranging from 5.5 to 29.9 mm and 4.0 to 5.0 mm, respectively. All patients with MCS ≥5.5 mm on injury radiographs had complete DDL injury and all patients with MCS ≤5.0 mm on injury radiographs had partial DDL injury. CONCLUSION: Complete DDL injury was found on injury ankle mortise radiographs as MCS widening of ≥5.5 mm, which correlated with arthroscopic visualization of the PTT. Using this cutoff, surgeons can surmise the presence of a complete deltoid ligament injury, allowing for improved preoperative planning. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Effect of Early Weightbearing Following Open Reduction and Internal Fixation of Unstable Ankle Fractures on Wound Complications or Failures of Fixation.

BACKGROUND: There is a growing trend toward early weightbearing as tolerated (WBAT) after open reduction and internal fixation (ORIF) of ankle fractures. To date, studies have excluded fractures with associated syndesmotic injuries from their cohorts. METHODS: In this retrospective cohort study, a chart review was performed at a single level 1 trauma center, identifying all unstable ankle fractures that underwent operative fixation between July 2016 and July 2017. After exclusion criteria, 63 patients were identified and 31 were included in the final analysis, with 14 undergoing syndesmotic fixation. WBAT was initiated after suture removal, between 2 and 4 weeks postoperatively. Outcomes included fracture union, radiographic maintenance of alignment, hardware failures, wound complications, and the need for repeat surgery. RESULTS: Weightbearing was initiated at an average of 17.8 days. All 31 patients progressed toward fracture union, with no hardware failures. Three patients developed superficial wound breakdown, which was treated with protected weightbearing in all cases and oral antibiotics in 1 case. All 3 went on to heal from their incisions. One patient had delayed wound breakdown and required a split-thickness skin graft that subsequently healed without complication. One patient underwent hardware removal 6 months postoperatively. There were no revision ORIF procedures. CONCLUSION: There is literature supporting early WBAT after ORIF of unstable ankle fractures in patients without major comorbidities. This article supports this trend, demonstrating that a group of ankle fractures requiring syndesmotic fixation were included in the early weightbearing cohort without a higher rate of catastrophic failure or increased wound problems. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Accuracy of Anterior Superior Iliac Spine Symmetry Assessment by Routine Structural Examination.

CONTEXT: Assessment of the anterior superior iliac spine (ASIS) is a key component in generating the pelvic diagnosis of somatic dysfunction, but studies have shown poor reliability between examiners. OBJECTIVE: To assess the influence of homogeneous training, years of experience, and eye dominance on the percentage of correctness, sensitivity, and specificity of ASIS evaluation. METHODS: Osteopathic physicians, predoctoral teaching fellows, and first- and second-year osteopathic medical students from a single teaching institute assessed 3 plastic pelvic models with ASIS anatomic landmarks set at different levels: even and 5- and 10-mm descrepancies. Dominant and nondominant eyes were used independently to assess ASIS levels. RESULTS: A total of 147 examiners (participants) participated in this study (66 first-year and 61 second-year medical students, 15 fellows, and 5 osteopathic physicians). The overall percentages of correct results were 31.0% (even levels), 82.8% (5-mm discrepancy), and 91.7% (10-mm discrepancy). Differences by level of training were statistically significant only for the 5-mm ASIS discrepancy, where participants with more experience performed better. The overall sensitivity was 82.8% (5-mm discrepancy) and 91.7% (10-mm discrepancy), and the specificity was 31.0%. No statistically significant differences were found in the percentage of correct results by eye dominance. CONCLUSION: Assessment of ASIS is sensitive but not specific at discrepancies of 5 mm or greater. Length of experience positively influences the percentage of correct results, and eye dominance does not significantly change this outcome. This form of assessment can be used to screen for ASIS asymmetry.